Medication Assisted Treatment: The complications and risks of polysubstance abuse

M.A.T. and polysubstance abuse

One of the concerns of Medication Assisted Treatment (M.A.T.) and polysubstance abuse is that while M.A.T. has some efficacy for those addicted to opioids, many individuals  are addicted to or use additional substances that are not addressed by  the medications utilized under the M.A.T. umbrella.

Polysubstance dependence, according to the book Modern Medical Toxicology [1], is defined as follows: “For a period of at least twelve months, a person has repeatedly and indiscriminately used substances from at least three groups of substances (excluding caffeine and nicotine) but no single substance has predominated. During this period, the dependence criteria were met for substances as a group but not for any specific substance.”

In other words: Afflicted individuals are addicted to the “high” more than they are specific substances. While there are individuals who come to the drug and alcohol treatment center Cornerstone of Recovery addicted to one drug only, they’re not the norm, according to Cornerstone Clinical Director Dr. Scott Anderson.

“It does happen, but I would say it’s much more common to have people who are polysubstance users or abusers,” Anderson says. “My thought is that the majority of people use multiple substances.”

And that, according to experts, presents a conundrum for providers of M.A.T.: Yes, M.A.T. can be beneficial for those addicted to opioids, but is it truly an effective therapy if that individual has just as much of a problem with stimulants, benzodiazepines or other drugs that fall outside of the physiological assistance that M.A.T. provides?

Polysubstance Abuse: What We Know

M.A.T. and polysubstance useIn recovery parlance, it’s known as a “drug of choice”: the substance for which those who meet the clinical diagnosis for substance use disorder (commonly known as addiction) have a preference. If polysubstance users were to pick one, however, the only applicable answer would be “more.” And for addiction treatment providers, as well as recovery activists pushing back against the ongoing national overdose epidemic around the country, that’s particularly worrisome, Ray Hainer, in an article for Boston Medical Center [2], writes: “While combining opioids with other drugs is hardly new — people have been injecting mixtures of heroin and cocaine for more than a century — clinicians and researchers describe a worrisome increase in the number of people who are routinely supplementing opioids with drugs including methamphetamine, cocaine, and benzodiazepines.

“This rise in polysubstance use (as it's known in the literature) is scary for several reasons. Although effective medications for opioid use disorder (OUD) exist, the lack of comparable treatments for stimulant addiction complicates the path to recovery for those using multiple substances.”

So where do treatment providers see polysubstance abuse most often? At Cornerstone of Recovery, those patients come from across the socio-economic spectrum, but research reveals that there are certain populations where it presents more frequently. Writing for the journal Current Opinion in Psychiatry [3], Australian researchers found that:

  • “Wide-ranging polysubstance use is more prevalent in sub-cultures such as ‘ravers’ (dance  club  attendees), and those already dependent on substances.”
  • While teens report polysubstance use in the limited range — meaning the substances are limited to alcohol and marijuana — the percentage of those who do is between 18 and 34 percent. Researchers also found that “limited range polysubstance use in adolescence may increase the risk of expanded polysubstance use in young adulthood.”
  • “Young adult males (around 18-35 years) are at elevated risk of extended polysubstance use.”

So how do polysubstance addictions develop? The same as any other addiction, of course, but the reasons for addiction to multiple substances can best be attributed to several commonalities, according to researchers writing for the fall 2020 edition of the International Journal of Drug Policy [4], including: “obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported.”

Of particular importance when it comes to M.A.T. and polysubstance abuse, researchers noted, is that another presenting reason for addiction to multiple substances is “Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary ‘issue’ drugs.”

It's one of reasons, Anderson believes, that while M.A.T. can work well for some patients, others find that while their cravings for opioids are satiated by a medication like buprenorphine, their desire for other substances — and to the high that all substances provide — is not.

“I think everybody uses in order to change the way that they feel,” Anderson says. “They want to achieve that high, that altered state of being and feeling, and many times when you either take away access to a particular drug, or a person takes something like Suboxone or methadone in order to partially satisfy the craving for that drug, then they turn to other substances, or possibly other behaviors, in order to achieve that high or that altered state of feeling. It’s not unusual at all for people to transfer their addiction from one substance to another.”

M.A.T. and Polysubstance Abuse: How It Can Make a Problem Worse

In many cases, those addicted primarily to opioids report common use of other substances anyway, according to the University of Washington School of Medicine [5]: Up to 70 percent of opioid use disorder patients, researchers found, report polysubstance use of other drugs, including:

All three substances, researchers have found — along with benzodiazepines and amphetamines — have been associated with overdose deaths in patients prescribed buprenorphine as part of their M.A.T. treatment for opioid addiction. Even the federal government, as part of its “Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction,” [6] warns against the dangers of M.A.T. and polysubstance abuse: “Abuse of multiple drugs (polysubstance abuse) by individuals addicted to opioids is common. Pharmacotherapy with buprenorphine for opioid addiction will not necessarily have a beneficial effect on an individual’s use of other drugs. Care in the prescribing of buprenorphine for patients who abuse alcohol and for those who abuse sedative/hypnotic drugs (especially benzodiazapines) must be exercised because of the documented potential for fatal interactions.”

And therein lies the possibility that M.A.T. treatment can actually facilitate polysubstance use: In 2017, the Food and Drug Administration (FDA) issued a Drug Safety Communication [7] that stated “benzodiazepines and other drugs that can depress the central nervous system do not have to be withheld from patients taking drugs such as buprenorphine or methadone for treatment of opioid addiction.”

M.A.T. and polysubstance abuseHowever, earlier this year in the online publication Addiction Professional, editor Gary Enos pointed out that [8] “a study of Massachusetts buprenorphine patients, published in Addiction, reports that patients who were taking a benzodiazepine at the time they were on buprenorphine had an increased risk of opioid overdose and all-cause mortality compared with buprenorphine patients not on a benzodiazepine.” Around one-third of buprenorphine patients are also prescribed benzodiazepines, the study added.

Such a wide-ranging approach to M.A.T., Anderson points out, is evidence that while such a therapeutic approach may work for some individuals who suffer from addiction, the latitude given to M.A.T. providers, some of whom don’t take polysubstance use into consideration, can also make problems worse.

“There are programs who test people and who try to ensure that they’re abstinent from other mood-altering chemicals, but there are other programs that don’t do that well,” he says. “And then there are programs where people are prescribed other mood-altering substances like benzodiazepines, or even stimulants for ADHD, and it’s accepted practice for patients to have access to those other mood-altering substances.

“Unless those programs are (drug) testing, then they really don’t know what other substances someone is taking. They’re only basically addressing one small part of the problem, and generally, I think the problem is more with addiction than it is with just opiate use.”

Addressing that addiction, he adds, is paramount. Already, polysubstance users present with greater signs of psychological distress, and “PSUD (polysubstance use disorder) is associated with poor treatment outcomes, and higher frequencies of comorbid mental disorders, including affective disorders, anxiety, and positive psychotic symptoms,” according to a March article in the journal Addiction Research and Theory [9]. “These adverse outcomes have been argued to be a result of dose–response relationship where increasing numbers of substances used result in more adverse effects on psychological health, an association which might be especially prominent during periods of active drug use.”

The Ingenuity of Addiction

Conventional wisdom might seem to indicate that if one drug is replaced through a process like M.A.T. — for example, a heroin addict switches to long-term methadone or buprenorphine maintenance — then the problem is solved. The heroin addict’s desire to use drugs is satiated, and the problems are no more. However, anecdotal evidence suggests otherwise — because addiction, Anderson points out, isn’t about a specific drug.

Take marijuana, for example. One of the arguments proponents of marijuana legalization used in pushing for its 2012 legislative passage in Colorado was that access to weed would cut down on the use of illegal drugs like heroin, cocaine and meth. Not so fast, points out Ben Cort, a recovering addict, speaker and proponent of marijuana reform who gives talks around the country on legalization and trends.

“My own experience, and that of other addicts I know, is that we’re not going to switch over to another drug,” he said in 2018. “Look at alcohol: It’s completely legal, just about anybody in the country can use it, and it’s far and away the most damaging, and I think that’s because it’s the most accessible — not because it’s so dangerous, but because there’s such a small perception of the risk of it and because of advertising and because of the powers that be. We don’t have the respect for it that we do for any mood-altering substance.

“Look at it this way: For the last three years, we’ve had the highest number of opioid overdoses in Colorado. I don’t think you blame weed for that; I think it’s a nationwide trend, but in our world, polysubstance use isn’t about weed or booze or heroin or sex. It’s about the holes we’re trying to fill with something. We want to get high because we hurt, and we want to not hurt.”

And where there’s money to be made with a substance to fill those holes and stop that hurt, those supplying the drugs they use will find a way. As Thomas Gounley pointed out in a 2017 report for the Springfield (Missouri) News-Leader [10], “just like any legal industry, there is a steady pace of innovation in the world of illegal drugs, typically in response to some government crackdown.” One example, he continued: “To combat meth in the early 2000s, laws were implemented requiring medications containing pseudoephedrine to be sold from behind the counter. In 2007, fewer than 7,000 meth labs were seized across the country. But makers and users adjusted, developing what became known as ‘one-pot’ or ‘shake-and-bake’ meth production, in which just a couple of pseudoephedrine pills are mixed in a 2-liter soda bottle for smaller batches. The new method led to another spike — 15,000 national meth lab busts in 2010.”

Similar reporting by the news website Politico in 2018 [11] demonstrated that many individuals addicted to prescription opioids didn’t just stop using as lawmakers began to crack down on opioid prescribing practices several years ago — they simply sought out relief and euphoria from other sources: “Some said they coped by using medical marijuana or CBD oil, an extract from marijuana or hemp plants; others turned to illicit street drugs despite the fear of buying fentanyl-laced heroin linked to soaring overdose death numbers.”

“I think that speaks to the mentality of the addict, which is  to get high by whatever means possible,” Anderson says. “Yes, you can enact laws, prosecute pharmaceutical companies, make certain ingredients illegal, etc., but unless you address the issues that are driving the behavior and the addiction, addicts will move on to another substance that satisfies their need. This is really where current policy/emphasis on the ‘opioid’ problem misses the mark, because addiction, rather than opiates, is the real problem.”

M.A.T. and Polysubstance Abuse: A Nuanced Approach

M.A.T. and polysubstance abuseAs Hanier points out [2], “the complexity of polysubstance use makes a one-size-fits-all solution all but impossible. Instead, providers must look beyond the available tools and develop tailored treatment programs,” and while medications like buprenorphine may play a critical role in the treatment of those addicted to opioids, it “may not be enough to stabilize people with multiple substance use disorders.”

In other words, long-term M.A.T., as it currently exists, would be ideal in a world where opioids are the only drugs of concern. However, treating opioid use disorder, says Dr. Jessie Gaeta, medical director of the Boston Health Care for the Homeless Program [2], "doesn't necessarily mean that the stimulant, benzodiazepine, and alcohol use disorders also go away. And it's sometimes a struggle to manage these other distinct addictions."

Ongoing research continues to verify Gaeta’s assertion: Researchers in a February 2020 article for the American Journal of Public Health [12] point out that “those with a prescription OUD had greater prevalence of other substance use disorders than misusers or general users of prescription opioids” … but that “the continued growth in the opioid epidemic has had the effect of creating a silo, so to speak, in that researchers and policymakers, particularly when it comes to treatment, increasingly are focused almost exclusively on (opioid use disorder) (e.g., medication-assisted treatment that targets only opioids) and its nuanced components (e.g., prevention of doctor shopping through prescription drug monitoring programs), rather than taking a more global view of substance use disorders per se.”

Effective treatment at a facility like Cornerstone of Recovery provides not just that global view, but an effective approach through traditional addiction recovery methods and a host of evidence-based psychotherapies. Known as a bio-psycho-social-spiritual approach to addiction treatment, these methods focus on whole-person wellness by addressing the disease of addiction, rather than a specific substance.

“There are differences in the bio-chemical processes associated with different drugs, but there are commonalities and similarities, too, that people try to seek, and that’s a component that’s often overlooked in M.A.T.,” Anderson says. “If we give the individuals tools to address the root cause of their addiction — the trauma, the family of origin issues, the poor coping skills, the environmental factors, etc. — then we help them to make improvements in all areas of their lives.

“M.A.T. and polysubstance abuse are complex issues, and while M.A.T. works for some people, it’s important not to lose sight of the fact that individuals suffering from addiction undergo specific biological changes in the brain that effect reward pathways in the brain. Targeting one drug through M.A.T. doesn’t address polysubstance abuse, which is what we aim to do at Cornerstone of Recovery.”

SOURCES

[1]: https://books.google.com/books?id=MFcHBAAAQBAJ&pg=PA545&lpg=PA545#v=onepage&q&f=false

[2]: https://www.bmc.org/healthcity/population-health/polysubstance-use-dangerous-fourth-wave-opioid-crisis

[3]: https://www.researchgate.net/publication/261287974_Polysubstance_use_Diagnostic_challenges_patterns_of_use_and_health

[4]: https://www.sciencedirect.com/science/article/abs/pii/S0955395920302735?dgcid=rss_sd_all

[5]: https://waportal.org/sites/default/files/documents/Session%203_Polysubstance%20Use_FINAL.pdf

[6]: http://lib.adai.washington.edu/clearinghouse/downloads/TIP-40-Clinical-Guidelines-for-the-Use-of-Buprenorphine-in-the-Treatment-of-Opioid-Addiction-54.pdf

[7]: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-urges-caution-about-withholding-opioid-addiction-medications

[8]: https://www.psychcongress.com/article/research-highlights-risk-benefit-analysis-around-buprenorphine-benzodiazepines

[9]: https://www.tandfonline.com/doi/full/10.1080/16066359.2020.1730822

[10]: https://www.news-leader.com/story/news/local/ozarks/2017/05/27/man-who-reinvented-meth/330877001/

[11]: https://www.politico.com/story/2018/08/28/how-the-opioid-crackdown-is-backfiring-752183

[12]: https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305412